The N
ENGLAND JOURNAL d MEDICINE
From the Medical Service, Veterans Af-
fairs Boston Healthcare System O.S.W., of cardiovascular health, including screening for hypertension and monitoring the
Endocrinology,
effectiveness of treatment in patients with hypertension. In the routine outpatient
Women's Hospital O.S.W., S.B., P.R.C.);
and Harvard Medical SchoolO.S.W.,
P.R.C.) — all in Boston.
N Engl J Med
Copyright O
Massachusstts Medica; Society.
Figure 1. Equipment used in blood.
pressure measurement.
e6
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VIDEOS IN CLINICAL MEDICINE
Blood-Pressure Measurement
Jonathan S. Williams, M.D., M.M.Sc.. Stacey M. Brown, M.S.,
and Paul R. Conlin, M.D.
INDICATIONS
Blood-pressure measurement is indicated in any situation that requires assessment
P.R.C.); the Division of
Diabetes, and Hypertension, Brigham and
setting, blood-pressure measurement is obtained indirectly. Proper techniques
are important to ensure consistent and reliable measurements.
CONTRAINDICATIONS
Measurement ofblood pressure at the brachial artery is a generally benign procedure.
However, there are some circumstances in which obtaining readings from a par-ticular
arm may not be appropriat.e; such circumstances include the presence ofan arterial—
venous shunt, recent axillary node dissection, or any deformity or surgical history that
interferes with proper access or blood flow to the upper arm. If these relative
contraindications are present, blood pressure should be assessed in the op-posite arm.
There may also be pre-existing conditions that can interfere with the ac-curacy or
interpretation of readings, such as aortic coarctation, arterial—venous mal-formation,
occlusive arterial disease, or the presence ofan antecubital bruit. Ifneither arm can be
used, then measurement ofblood pressure in a leg may be indicated.
EQUIPMENT
The essential equipment for blood-pressure measurement includes a stethoscope and a
sphygmomanometcr. The stcthoscopc tubing should be long cnough to permit thc
practitioner to auscultatc Korotkoff sounds while viewing the manomctcr at cye level.
Use ofthe bell side ofthe stethoscope chestpiece facilitates auscultation ofthe low-
frequency Korotkoffsounds. The sphygmomanometer consists ofa blood-pres-sure
cuffcontaining a distensible bladder, a rubber bulb with an adjustable valve for inflation,
tubing that connects the cuff to the bladder, and a manometer (Fig. 1). Regular
inspection and calibration of the equipment are important to ensure that
it is in proper working order. For accurate measurement, calibrations are recom-
mended every 6 months.1'2
Many institutions have removed mercury manometers from clinical settings and
replaced them with aneroid manometers. The steps required for accurate blood-
pressure measurement with an aneroid or a mercury manometer are identical.
PREPARATION
The examinacion room should be quiet, with a confortable ambient temperature. Ideally,
blood pressure should not be measured ifthe patient has engaged in recent physical
activity, used tobacco, ingested caffeine, or eaten within the past 30 minutes.3
N ENGL J MED 360;5 NEJM.ORG JANUARY 29, 2009
The New England Journal of Medicine
 BLOOD-PRESSURE MEASUREMENT

Positioning ofthe Patient

Correct positioning ofthe patient is essential for accurate measurement. The patient's
back and legs should be supported, with the legs uncrossed and the feet resting on
a firm surface.
The arm in which blood pressure Will be measured should be bare to the shoul-
der. and the garment sleeve, if raised. should be loose, so that it does not interfere
with blood flow or with proper positioning of the blood-pressure cuff. The arm
should be supported and level with the heart. The manometer should be positioned
at the health care practitioner's eye level.

Arm Measurement
A common error in measuring blood pressure is the use of an improperly fitted
cuff. Undersized cuffs Will result in overestimation of blood pressure. Selection of Acromion
an appropriately sized cuff requires assessment ofthe patient's arm circumference
at the midpoint ofthe upper arm. One halfthe distance between the acromion and
the olecranon processes determines the midpoint of the arm (Fig. 2). The circum-
e Ig.r.f:.lljen
ference is then measured at the midpoint.

CuffSizing
Fiaure 2. Arm measurements for
Cuffs are typically marked with line indicators intended to facilitate proper fitting.
assessing cuff size.
The index line runs perpendicular to the length ofthe cuff, and the range line runs
parallel to the length ofthe cuff. Once the cuff has been wrapped around the
arm, the index line should fall within thc range-line limits, and the midpoint
ofthe blad-der should sit over the brachial artery.
In addition to index and range lines, cuffs Will often indicate size or size ranges
(e.g., adult or large adult.). The sizes marked on the cuff should correspond to the
appropriate arm circumference (Table 1). Although these may be helpful guides, it is
most important to use a cuff size that is based on the arm measure-ment and on the
match between the index and range lines once the cuff is placed
40
on the patient. A cuff that is too small may contribute to a falsely elevated blood- pressure
measurement.

Cuff Placement
The cuffshould be placed on a bare arm, approximately 2 cm above the elbow crease,
with the midline ofthe bladder (usually indicated by the manufacturer) directly over
the brachial artery (Fig. 3). It should fit snugly but should Still allow for two fingers Figure 3. Proper positioning ofthe
to slide under the cuff. blood-pressure cuff.

Table 1. Blood-hessure CuffSizing.

Arm Circumference Bladder Dimensions Cuff Size

centimeters

22 to 26 12x22 Small adult arm

27 to 34 16x30 Adult arm
35 to 44 16x36 Large adult arm
45 to 52 16x42 Adult thigh

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 The NEW ENGLAND JOURNAL ó MEDICI N F.

Pulse-Obliteration Pressure
Inflating the cuff to an arbitrary level runs the risk of overinflation and undue pa-tient
discomfort or of underestimation of systolic blood pressure. To avoid under-estimation
ofblood pressure due to an auscultatory gap, determine the pulse-oblit-eration
pressure. which can be used to estimate an appropriate initial cuff-inflation pressure.
An auscultatory gap is present when there is intermittent disappearance of the initial
Korotkoff sounds after their first appearance. It is more likely to be present in Older
hypertensive patients and can lead to underestimation of systolic blood pressure.4
Estimating systolic blood pressure by first measuring pulse-obliter-ation pressure
helps to avoid an incorrect measurement of systolic blood pressure.
To determine the pulse-obliteration pressure, palpate the radial pulse while
rapidly inflating the cuffto approximately 80 mm Hg. Then Slow the inflation
rate to approximately 10 mm Hg every 2 to 3 seconds, taking note of the
reading at which the pulse disappears. After the pulse has disappeared, deflate
the cuff at a rate of 2 mm Hg per second, noting when the pulse reappears,
which confirms the obliteration pressure.

BLOOD.PRESSURE MEASUREMENT
Place the bell of the stethoscope over the brachial artery, using sufficient pressure to
provide good sound transmission without over-compressing the artery. To avoid
extraneous noise during cuffdeflation, ensure that the stethoscope is not in contact
with the patient's clothing or with the blood-pressure cuff.
Once thc pulse-oblitcration pressurc is dctcrmined, initiate the auscultatory
blood-pressure measurement by rapidly inflating the cuffto a level 20 to 30 mm
Hg above the pulse-obliteration pressure. Then deflate the cuffat a rate of2 mm
Hg per second while listening for the Korotkoff sounds.

KOROTKOFF SOUNDS
As the cuff is deflated, turbulent blood flow through the brachial artery generates a
series of sounds. Classically, these have been described according to five phases.
Phase 1 is characterized by a clear, repetitive tapping sound, coinciding with reap-
pearance ofa palpable pulse. The initial appearance ofphase 1 sounds is equal to the
systolic blood pressure. During phase 2, audible murmurs in the tapping sounds are
heard. In phases 3 and 4, muted changes in the tapping sounds occur (usually within
10 mm Hg of the true diastolic pressure) as the pressure measurement ap-proaches the
diastolic pressure. Phase 5 is not really a sound; it indicates the disap-pearance of
sounds and equates to the diastolic blood pressure.
To ensure that diastole has been reached, continue to deflate the cuff
pressure for an additional 10 mm Hg beyond the fifth Korotkoff sound.
Obtain a minimum of two blood-pressure measurements at intervals of at
least 1 minute.l Record the average of the measurements as the blood pressure.

BLOOD-PRESSURE CLASSIFICATION
Normal adult blood pressure is defined as a systolic pressure less than 120 mm
Hg and a diastolic pressure less than 80 mm Hg. Higher blood pressures are
consid-ered to indicate prehypertension and hypertension, which is also divided
into stages (Table 2).1

OBSERVER ERROR
A common error in blood-pressure measurement is the introduction of observer bias.
which occurs in two forms. The first occurs when practitioners show termi-nal-digit preference, and the second
occurs when practitioners round the terminal

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 BLOOD-PRESSURE MEASUREMENT

REFERENCES
Table 2. Blood-Pressure Classification. l. Pickering TG, Hall JE, Appel IJ, et al.
Recommendations for blood pressure
Classification* Systolic Diastolic measurement in humans and experimen-tal
animals. I. Blood pressure measure-ment in
humans: a statement for profes-sionals from
the Subcommittee
Norrnal <120
of
Prehypertension Professional and Public Education of
Stage the
I hypertension American Heart Association Council on
High Blood Pressure Research.
Stage II hypertension 160
Hyperten-sion
2. Beevers G, Lip GY, O'Brien E. ABC of
For classification of blood pressure as normal, the requirements for both systolic and diastolic hypertension: blood pressure measure-
pressure must be met; for the remaining categories, either the systolic or the diastolic requirement ment. II. Conventional sphygrnomanome-try:
must be met. technique of auscultatory blood pres-sure
measurement. BMJ 2001;322:1043-7.
3. Chobanian AV, Bakris GL, Black H.R*
digits, as when recorded blood-pressure levels are rounded to a O or a 5.1 Manom- et al. Seventh Report ofthe Joint National

eter scales are generally scored in 2-mm increments, so a terminal digit of5 cannot

Comrnittee on Prevention, Detection, Eval-

uation, and Treatment of High Blood
be read and the terminal digit 0 should occur only 20% of the time. Use ofan ap- Pressure. Hypertension
propriate deflation rate and careful recording ofthe appearance and disappearance
4. Perloff D, Grim C, Flack J, et al. Hu-

ofKorotkoff sounds generally facilitates precise measurement. man blood pressure determination by
sphygmomanometry. Circulation 1993;88:

A parallax error may occur when mercury manometers are used if the observer 2460-70.
is not at eye level with the mercury column. Such misalignment between the eye Copyrigh: @ 2009 Massachusetts Medical Society.
and the mercury meniscus may cause the meniscus to be read as higher or
lower than the actual position.

SPECIAL CIRCUMSTANCES
Certain clinical conditions may complicate blood-pressure measurement or its
inter-pretation. In the case of arrhythmias and dysrhythmias, irregularity in the
timing of Korotkoff sounds (e.g., atrial fibrillation) can decrease the accuracy of a
mea-surement. Accuracy can be improved by decreasing the deflation rate and by
taking an average of several measurements.
Atherosclerotic vascular disease can result in the persistence of audible
Korot-koff sounds (prolonged Korotkoffphase 4 or absence ofphase 5) despite
deflation to 0 mm Hg. This is called persistent systole and may occur in Older
patients and during pregnancy. In this situation, diastole should be estimated
by noting the appearance of the fourth Korotkoff sound.
Occasionally, a patient with an exceptionally large arm circumference requires a
cuff size that cannot be adequately positioned between the antecubital fossa and the
upper arm. This can lead to patient discomfort and inadequate compression of the
brachial artery. If an appropriate cuff cannot be fitted above the brachial artery, then it
may be better to place a cuff on the forearm with auscultation of Korotkoff sounds at
the radial artery. Care should be taken to ensure that the forearm is supported level
with the heart. If the forearm is below heart level. a false elevation in pressure may
occur, owing to increased hydrostatic forces.
Normal blood pressure fluctuates over a 24-hour period. In some situations, it
may be prudent to obtain measurements at different times during the day, par-
ticularly when diagnosing or monitoring hypertension. It is also important to
consider the timing and type of antihypertensive medications used when
interpret-ing blood-pressure measurements in hypertensive patients.
Dr. Conlin rcports receiving lecturc fces from Merck. No Other potencial conflict of interest relevant to
this article was reported.

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